St Oswalds

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence people were protected from abuse and avoidable harm.
This is the first assessment for St Oswalds Care Home. This key question has been rated requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The provider did not always have a proactive safety culture. Not all significant incidents were effectively reviewed, and lessons were not consistently learned to improve practice. For example, although there were many incidents involving wounds and unexplained bruising, there was limited evidence these were fully reviewed to ensure staff followed safe and appropriate practices. People did not receive consistent support to manage risks related to their health and wellbeing because lessons from previous incidents were not embedded into practice.

However, we found evidence some incidents were discussed with staff during team meetings, and staff routinely reviewed incidents and changes in people’s needs during handovers.

Although the provider worked with people and healthcare partners to establish and maintain safe systems of care, they did not ensure there was continuity of care, including when people moved between different services. For example, records of a person’s initial assessment was not properly completed. Important details were missing, such as how they liked their personal care to be carried out. Information about their skin health was not recorded in their initial assessment even though they had skin‑related concern which required attention.

However, feedback from other healthcare professionals was positive, comments included, “I find management is receptive to my visits and responsive to any feedback I have provided.”

The provider did not always work effectively with people or healthcare partners to understand what being safe meant to them or how to achieve this.

Concerns were not always shared promptly or appropriately with relevant organisations such as the local authority and CQC. We identified an incident which required safeguarding action and notification to the CQC; however, this had not been completed. This failure placed people at risk of harm.

However, people were supported by staff who had received safeguarding training and understood how to recognise and report concerns. Staff told us they would raise any issues with management. Despite this, the registered manager did not always demonstrate a full understanding of their own responsibilities to report incidents in line with safeguarding guidance and CQC requirements.

The provider did not always work well with people to understand the risks they faced or how to manage them safely. Staff did not always give care that fully met people’s needs or helped them live safely and independently. Some important risks had not been assessed, which meant people were not always protected from harm. For example, people living with conditions such as diabetes, asthma or epilepsy did not have specific risk assessments in place. This meant staff did not have clear guidance on how these health conditions affected the person, how to spot early signs of a change in their health, or what to do in an emergency. Without this information, staff may not have been able to respond quickly or effectively if a person became unwell.

The provider did not consistently identify or control potential risks within the care environment. Not all equipment was regularly serviced for safety and we found areas of risk which needed to be addressed. For example, some windows did not have window restrictors in place, management informed us they were aware of this however, nothing had been done. Additionally, the home had stairs leading to the upper floor. There was no risk assessment in place to manage the risks for people who were mobile and able to access the stairs. Although the provider stated there had been no previous incidents involving people using the stairs, we identified an incident where a person was found wandering during the night. This demonstrated the risk was present and not adequately managed, placing people at potential risk of harm.

Management addressed our concerns with window restrictors during our assessment.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care which met people’s individual needs. The provider completed pre-employment checks prior to staff deployment. However, they did not always make sure staff received necessary training. Some staff training had expired, which included mandatory and person specific training. This included training for supporting people with COPD, epilepsy and asthma. We raised this with the provider who assured us they were working with the local college to support with further training for specific conditions. Evidence of staff completing their training was sent after our assessment.

Training opportunities were available for care staff to complete the care home assistant practitioner course [CHAP] to support staff development. A member of staff told us, “We are given the opportunity to complete training, Warrington Borough Council offers us training we can book on and attend.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Improvements were needed to infection prevention and control. Some areas of the home were showing signs of wear and tear. The home had malodours smell in some areas. We spoke with one relative who told us, “The residents rooms are being decorated however, in the corridor into the residents rooms there is a smell all the time.” We raised this with management who promptly looked into addressing the issue.

Staff confirmed they had received infection control training and they told us personal protective equipment (PPE) and all cleaning materials needed were available.

The provider did not always ensure medicines and treatments were safe or met people’s needs, capacity, and preferences. Although staff involved people in planning their care, risks associated with certain medicines, such as thickening agents and insulin, were not always fully considered.

We spoke with a person who required staff support to manage their diabetes. They told us they did not always receive their food promptly after being given insulin, which had resulted in low blood sugar levels. This posed a serious risk to their health. We found some thickening agents and prescription creams were not kept securely despite there being locked medication cabinets available. We raised this with management who promptly rectified the situation.

In other instances, people received their medicines safely and as prescribed by a trained and competent staff team.